Following the death of Joseph Scholes, a 16 year old boy who died at Stoke Heath Young Offender Institution in 2002, there was widespread public and parliamentary concern and calls made for a public inquiry.

That inquiry never took place and since Joseph died on 24 March 2002, nine children and 191 young people aged 24 and under have died in prison or, in the case of two of the children, imprisoned in a secure training centre.

The report, commissioned by the Prison Reform Trust as part of its Out of Trouble five year programme to reduce child and youth imprisonment, supported by the Diana, Princess of Wales Memorial Fund, is based on the unique dataset compiled by INQUEST through its specialist advice and casework service, supporting the families of children and young people through the investigation and inquest process. In particular, the experiences of 98 children and young people who died between 2003 and 2010 are looked at in detail, forming the basis for the findings and recommendations contained in the report.

For the first time, this analysis reveals the systemic failings that have contributed to some of the deaths of young people aged 18-24. Often overlooked and neglected in a regime that does not differentiate between young adults and adults, there is little institutional understanding of, or attention to, their specific needs.

The report found that the children and young people who died:

were some of the most disadvantaged in society and had experienced problems with mental health, self-harm, alcohol and/or drugs;

had significant interaction with community agencies before entering prison yet in many cases there were failures in communication and information exchange between prisons and those agencies;

despite their vulnerability, they had not been diverted out of the criminal justice system at an early stage and had ended up remanded or sentenced to prison;

had been exposed to bullying and treatment such as segregation and restraint;

were failed by the systems set up to safeguard them from harm.

The analysis also found there had been inadequate institutional responses to the deaths of children and young people in prison. Investigations and inquests are subject to lengthy delay and mechanisms are currently inadequate to ensure learning is acted upon by all relevant agencies.

Deborah Coles, co-director of INQUEST said:

These deaths are the most extreme outcome of a system that fails some of society’s most troubled and disadvantaged children and young people. This shocking death toll has been obscured for far too long and for the first time, we now have a clear picture of the extent of the problem and the fatal consequences of placing vulnerable young people in unsafe institutions ill equipped to deal with their complex needs.Working on a daily basis with bereaved families we see inquest after inquest raising the same issues and despite promises of change the deaths continue as illustrated by the self inflicted deaths of two children and eight young people already this year.It is difficult to comprehend how despite the persistent death toll there has been a repeated refusal and resistance to holding a holistic inquiry to examine the wider systemic and policy issues underlying the deaths of children and young people in custody. This report must prompt an independent review as a matter of urgency as there is a pressing need to learn from the failures that cost these young people their lives.

Yvonne Bailey, mother of Joseph Scholes, said:

I have read the report with sorrow. It is now over a decade since my son Joseph died in fear and distress hanging from the window bars of his squalid cell in a children’s prison. While I welcome the changes and improvements that have taken place in the prison estate during the last ten years - changes which would almost certainly not have taken place had it not been for the tireless work carried out by INQUEST, the Prison Reform Trust and others - the deaths of a further nine young boys are devastating evidence that the changes implemented were yet again wholly insufficient to fulfil the duty on the state to protect the right to life of the children it imprisons.

I am saddened and perplexed by the continuing and repeated refusal of successive governments to properly investigate through a public inquiry the circumstances that have led to the deaths of child prisoners.

Juliet Lyon, Director, Prison Reform Trust, said:

Every young death in custody is a tragedy made all the more harrowing when such deaths could be prevented by effective safeguarding measures and greater cooperation between health, welfare and criminal justice agencies.

After 200 deaths in ten years it is time to learn that locking up our most vulnerable children and young people in our bleakest institutions is a process that is fatally flawed.

The former Chief Inspector of Prisons, Lord Ramsbotham, writing in the foreword to the report, said:

Too often ‘tough’ talk about crime and punishment does not result in the authoritative action needed to rectify the flaws in our criminal justice system. This system and services in the community, whose failures are described in the report, have demonstrably let young people down, for all the wrong reasons, for far too long. I wholeheartedly endorse this report’s final recommendation that an independent review be established, with the proper involvement of families, to examine the wider systemic and policy issues underlying the deaths of children and young people in prison.

1. ‘Fatally Flawed: Has the state learned lessons from the deaths of children and young people in custody’ is being launched on 24 October at a roundtable in the House of Lords chaired by the former Chief Inspector of Prisons, Lord Ramsbotham.

2. This report by INQUEST was commissioned by the Prison Reform Trust as part of its Out of Trouble five year programme to reduce child imprisonment, supported by The Diana, Princess of Wales Memorial Fund.

3. The report’s full recommendations for change with the aim of preventing further deaths of vulnerable children and young people in prison are:

1) The custody threshold should be raised to ensure imprisonment becomes a true last resort, and is reserved for the minority of children and young people who commit serious violent offences and who pose a significant risk to others. Custody should not be the default response to low-level persistent offending.

2) Minor offences and anti-social behaviour committed by children and young people should be viewed as a public health, rather than criminal justice, issue and diverted to the health, welfare and other agencies which are best-placed to tackle it.

3) A common assessment framework which is built on a shared understanding of vulnerability should be developed for use by welfare and criminal justice professionals, so as to avoid the arbitrary distinction made by many statutory services between children and young people.

4) Sentencers must be better aware of the principles and sentencing guidelines which should underpin their decisions about the use of custody for children and young people.

a) Comprehensive training should be provided for sentencers (in both youth and Crown courts) and their legal advisers to enable better identification of complex needs, vulnerability and the court’s options under mental health legislation.

b) Full up-to-date information on locally available alternatives to custody for children and young people should be available to the courts.

5) A new, distinct secure estate with an emphasis on therapeutic environments and interventions should be developed for the minority of children and young people whose offending is so serious that only a secure placement can be justified.

6) Research on the distinct support needs of 18-24 year olds in custody, how they differ from those of adult prisoners, and how they are best identified and addressed should be urgently undertaken.

7) A clear system for identifying and managing looked after children and care leavers in custody, and ensuring the input of all statutory partners including social workers, youth offending practitioners and staff in the secure estate, should be introduced.

8) A review of the operation of the ACCT scheme should be conducted with a view to improving the accuracy of assessments and providing better support to those identified as at risk of harm.

9) Substantial improvements are needed in the availability and quality of mental healthcare provided to children and young people in custody.

a) Imminent changes to healthcare provision in prisons should be taken as an opportunity to drive up standards.

b) Procedures for transferring prisoners out of the secure estate under mental health legislation should be re-examined, and, where necessary, updated with new guidelines.

10) Delays in the inquest process must be addressed as a matter of urgency to ensure bereaved families do not have to wait years to hear the circumstances of a relative’s death in custody, and that organisational learning from deaths is timely.

11) Families bereaved by a death in custody should be eligible for public funding to enable their legal representation at inquests.

12) All coroners’ Rule 43 recommendations and juries’ narrative verdicts should be publicly accessible through a national database and analysed, audited and brought to the attention of Parliament to ensure responses from relevant Ministers.

13) An Independent Review should be established, with the proper involvement of families, to examine the wider systemic and policy issues underlying the deaths of children and young people in custody. As a starting point the Ministerial Council on Deaths in Custody should commission a new working group of the Independent Advisory Panel to draw together the specific learning from recent deaths of children and young people and identify issues for an independent review to consider.

Prison Reform Trust (PRT) is an independent UK charity working to create a just, humane and effective penal system.

We do this by inquiring into the workings of the system; informing prisoners, staff and the wider public; and by influencing Parliament, government and officials towards reform.

The Prison Reform Trust's main objectives are:

reducing unnecessary imprisonment and promoting community solutions to crime

improving treatment and conditions for prisoners and their families

The Prison Reform Trust provides the secretariat to the All Party Parliamentary Penal Affairs Group.INQUEST is a charity that provides a general telephone advice, support and information service to any bereaved person facing an inquest and a free, in-depth specialist casework service on deaths in custody/state detention or involving state agents and works on other cases that also engage article 2 of the ECHR and/or raise wider issues of state and corporate accountability.

INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.